April 2024 Pick of the Month

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Reducing the Misery of Rib Fractures

Rib fractures cause severe pain and patients who are discharged with rib fractures frequently return to the emergency department (ED) seeking pain control. Some return for several visits, leading to hospital admission solely for pain control. Many patients require high dose narcotics or epidural anesthesia for pain control -- neither of which are good options in outpatient treatment. In this month’s POTM, Efficacy and safety of ultrasound-guided erector spinae plane block compared to sham procedure in adult patients with rib fractures presenting to the emergency department: A randomized controlled trial, Ramesh and colleagues explore the ability of erector spinae plane block (ESPB) to reduce pain and increase the ability to breathe compared with an actual sham procedure (not often seen).

Many emergency physicians (EPs) had never heard of ESPB until recently. On the other hand, many have heard of or even performed rib blocks, which seem (in one editor’s experience) to usually produce so-so results, especially in patients with more than one rib fracture. The ESPB appears more effective than rib blocks, technically easier to perform, and likely carries a lower risk of pneumothorax. The data in Table 2 suggest that in experienced hands, the ESPB can quickly and significantly reduce patient-reported pain and allow them to breathe easier, which would lead to less narcotic use. The authors note that they believe this is the first randomized trial of ESPB in the ED setting. If their findings are repeated, ESPB could become another ultrasound-driven innovation that improves patient care by reducing the misery from rib fractures.


Jeffrey A. Kline, MD
Wayne State University School of Medicine